Provider Demographics
NPI:1255803813
Name:WILLIAMS, AMY MARIE (LAC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:THIELE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:309 NICOLLET AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003
Mailing Address - Country:US
Mailing Address - Phone:507-382-9452
Mailing Address - Fax:
Practice Address - Street 1:213 PARKWAY AVE
Practice Address - Street 2:
Practice Address - City:EAGLE LAKE
Practice Address - State:MN
Practice Address - Zip Code:56024
Practice Address - Country:US
Practice Address - Phone:507-382-9452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-20
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1886171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist